Professional Documents
Culture Documents
Nyeri Neuropatik
Nyeri Neuropatik
Nyeri Neuropatik
doi:10.1093/bja/aet206
Division of Population Health Sciences, Ninewells Hospital & Medical School, University of Dundee, Dundee DD2 4DB, UK
Specialist in Pain Medicine, Cayman Islands Hospital, University College London, PO Box 915, Grand Cayman KY1-1103, London, UK
3
University College London, London, UK
4
Pain Clinic, University Hospital of Southampton, Tremona Road, Southampton, Hampshire SO16 6YD, UK
5
Pain Management Centre, National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG, UK
2
Summary. Neuropathic pain is a common chronic pain condition that can be challenging
to treat, particularly for non-specialists. The development of the Map of Medicine care
pathway for the management of neuropathic pain was led by the British Pain Society.
Focusing on treatment by non-specialists, this pathway is based on new evidence,
consensus, and the interests of service users. This paper presents the care pathway
and accompanying evidence base, highlighting its salient features, and discussing
important treatment points. After initial assessment, the pathway progresses through
first-, second-, and third-line drug treatment, includes advice on topical treatment
and opioids (in specific circumstances), and describes non-pharmacological
approaches. Importantly, timely review of patients and referral to specialist
secondary or tertiary care must be considered as vital components of the pathway.
Although the emphasis was not on specialist treatment, advice is given on existing
interventions, including neural stimulation and multi-disciplinary care. These, and
other steps on the pathway, will be subject to further review as more evidence
becomes available. In the meantime, the pathway represents a straightforward,
valuable and accessible approach for healthcare professionals managing the distress
and impact of neuropathic pain.
Keywords: nerve pain; neuralgia; neuropathic pain
Neuropathic pain
Chronic pain has been shown to affect up to 46% of the adult
population, with .5% reporting high intensity, severely disabling chronic pain.6 7 The recent Health Survey for England found
that 31% of men, and 37% of women reported chronic pain.8
& The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
BJA
Table 1 Common causes of neuropathic pain
Peripheral
Painful diabetic neuralgia
Post-herpetic neuralgia
Trigeminal neuralgia
Lumbar radiculopathy
Nerve damage, including postoperative
Pain because of cancer tumour infiltration
Central
Post-stroke pain
Multiple sclerosis
Chemotherapy-induced pain
General
Idiopathic
Smith et al.
74
BJA
Neuropathic pain
Both the NICE guidance and this pathway are intended for use
by non-specialists. In this context, specialist refers to a professionals knowledge, experience and resources for managing
neuropathic pain. So, while most non-specialist doctors will be
general practitioners, the pathway is also aimed at consultants
and others expert in their own special field (e.g. diabetes and
orthopaedics), who need to know how to manage a patient
with neuropathic pain, according to current standards. Professionals who manage neuropathic pain all the time, already
working according to international standards, can deviate
from the pathway according to their specialist knowledge.
They are also likely to be those furnishing the details of the
final parts of the pathway, including supervising specific medications, coordinating multi-disciplinary interventions and
providing surgical treatments.
Initial assessment
Some helpful practical advice about the clinical presentation
and the diagnosis of neuropathic pain is provided. As highlighted above, this will alert the physician to the presence of
possible neuropathic pain. A brief but careful history and examination is the key to this diagnosis, along with an awareness of
the need to consider neuropathic mechanisms in anyone presenting with pain. Simple screening tools, such as the Leeds
Assessment of Neuropathic Symptoms and Signs (LANSS)
and PainDETECT,29 are available to assist in diagnosis, but are
not considered a substitute for these basic clinical skills, and
their positive predictive value in the primary care setting is
unknown.18 These questionnaire instruments share elements
in common with the advice provided in the pathway. Questions
about altered sensation and numbness in the area of pain,
evoked, or spontaneous pain sensations of unpleasant character (e.g. shooting or burning pains) are important. Similarly,
the demonstration of absent or altered sensation in the relevant area, in response to pinprick, vibration, hot, or cold pressure, or simple touch is important. The extent to which a
practitioner will be able to test these will depend on the
context in which he/she is working, but minimal testing
should always be possible, allowing the decision on whether
to embark on the pathway.
Reviewing progress
An important point that recurs in the pathway (and NICE guidance) is recommendations for the interval between reviewing
changes in medication. These are important in determining
when to move from first- to second- then third-line treatment.
A maximum review period of 2 weeks after initiating any treatment is specified. This allows: (i) the assessment of any effectiveness of the new treatment in improving symptoms; (ii) the
titration of dose as required; and (iii) the assessment of any
adverse reactions and the response to these. In most cases,
the starting dose will be lower than the maximum tolerated
75
BJA
Smith et al.
Key
More information
Care map
information
Information resources
for patients and carers
Referral
National info
Local info
Notes
Pharmacological
information
Possible neuropathic
pain clinical
presentation
Primary care
Secondary care
Go to complex
regional pain syndrome
First-line treatment
Second-line treatment
Add in tramadol as
third-line treatment
Consider interventional
pain therapies and
medications that
require specialized
supervision
Provide a
multi-disciplinary
review to consider
treatment options
76
BJA
Neuropathic pain
effective dose, and this early review will optimize the interval to
achieve this, thereby minimizing suffering. Another important
timing point is that at which specialist referral (if required)
is made. In summary, this should be immediate if the pain is
severe, causing significant distress, if any red flag factors are
present, or if diagnosis is difficult. Crucially, treatment should
continue, according to the pathway, while specialist review is
awaited. Otherwise, specialist referral should be made after
third-line treatment is proved unsatisfactory, if diagnostic uncertainty remains, or both, with a maximum of 6 months as
the initiation of first-line treatment. Again, treatment should
continue, for example, with the introduction of strong opioids
in accordance with BPS guidelines23 and according to the physicians experience and skills. These approaches are intended
to reduce the occurrence of refractory neuropathic pain,
which is associated with particular suffering, disability, and
healthcare use.11
Topical treatments
The pathway recommends use of topical treatments for localized causes of neuropathic pain, such as post-herpetic neuralgia, perhaps even before first-line treatment is given. This is at
odds with the NICE guidance, which concluded that: (i) there
was insufficient evidence to support the general use of weak
topical agents, such as capsaicin 0.075% cream or lidocaine
patches; and (ii) capsaicin 8% patches (for which the evidence
is stronger) are currently intended for specialist use.28 They are
included in this with the principle that no absence of effectiveness is not equivalent to evidence of ineffectiveness. Systemic
agents cause significant side-effects and drop-out from treatment is therefore common. There is good clinical consensus
that topical agents are effective in certain circumstances,
they may prevent the need for systemic therapies and contingent adverse reactions and interactions, and there was strong
patient-representative preference expressed for their use
during the development of the pathway. Finnerup and colleagues31 recommended the use of topical therapies for focal,
Carbamezapine
The pathway makes a clear recommendation for using carbamazepine as first-line therapy in the case of trigeminal neuralgia. The studies of carbamazepines efficacy date back to the
1960s and are well summarized in the American Academy of
Neurologys guidelines on the management of this condition.33
There are some subsequent comparison studies described in
this guideline and subsequently,34 but the studies have small
numbers of recruits. The NICE neuropathic pain guidelines
made several suggestions for further research in this area to
confirm the clinical suspicion that carbamazepine holds its
place as first-line therapy. Until this has been done, there is
little argument to make any change from current recommendations.
Strong opioids
The use of strong opioids in chronic non-malignant pain, including neuropathic pain, is controversial, but their judicious
use is recommended in later parts of this pathway. Before prescribing strong opioids, the prescriber should screen for risk of
an addiction disorder, either based upon the history or using
a standard screening tool. Additionally, evidence is emerging
from US studies of the importance of maintaining a ceiling
morphine equivalent dose of no more than 120 mg in adults
and 50 mg in the elderly, and prescribing modified release
preparations only.35 36
There is reasonable evidence for the effectiveness of strong
opioids in the short- and medium-term, and though long-term
effectiveness remains incompletely assessed, there is good
77
BJA
consensus that this is likely.23 However, what is unequivocal is
their potential for harm, including sedation, constipation,
hyperalgesia, reduced immunity, hormone suppression, and
dependence.22 35 36 Therefore, their use should be restricted
to refractory cases and to supervision by physicians experienced in their use and the assessment of the associated risks
and outcomes. Excellent guidance on this is available, as a consensus between the BPS and the Royal Colleges of Anaesthetists, General Practitioners, and Psychiatrists.23 Key to this is
detailed discussion with patients at the outset of treatment,
including agreed treatment goals, and knowledge of equivalent doses between different opioids.
Conclusions
This pathway provides a useful approach to the management
of neuropathic pain by non-specialists, and indicates approaches that may be used in specialist secondary care. With
a basis in existing sources of best evidence and consensus, it
gives the opportunity for confidence in addressing this challenging and unpleasant clinical condition, while also paying attention to the co-morbidities that often accompany it. The
keys to its successful implementation, at the individual level,
are attention to the patients specific needs, early review of
the response to any treatment and referral for specialist assessment when it is clear that treatment is not working. In
this way, combining professional healthcare skills with the
pathway outlined here, the burden of neuropathic pain on
our patients can be reduced.
78
Smith et al.
Supplementary material
Supplementary material is available at British Journal of Anaesthesia online.
Acknowledgements
The authors of this paper wish to acknowledge the following in
the production of the British Pain Society Neuropathic Pain
Patient Pathway: Map of Medicinew The Neuropathic Pain
Care Map which can be found at www.mapofmedicine.com,
and of which an extract is included in this article, is published
with the authorization of Map of Medicine Limited who owns
the copyright; British Pain Society Pain Patient Pathway Maps
Executive Committee: Andrew Baranowski (Chair), Martin
Johnson, Richard Langford, Cathy Price; British Pain Society
Neuropathic Pain Patient Pathway Map working group (in
addition to authors): Dave Bennett, Sam Chong, Andrew Rice,
Mick Serpell, Heather Wallace.
Declaration of interest
All authors contributed to the design and writing of this paper,
without any financial or other assistance. B.H.S. was a
co-investigator in neuropathic pain epidemiology research
funded by Pfizer (unrestricted educational grant) Consultancy:
Pfizer; Treasurer of Neuropathic Pain Special Interest Group,
International Association for the Study of Pain; Director, Scottish Pain Research Community. J.L. is a member of the
medical charity SPIN (Specialists in Pain International
Network). C.P. Meeting travel: Napp; executive member of
Chronic Pain Policy Coalition; executive member of the BPS
Pain Patient Pathway Maps Executive Committee and
member of its Implementation Committee; a member of the
medical charity SPIN. A.P.B. is Chair of the NHSCB, Clinical Reference Group for Specialised ServicesPain, England; advisor
on Specialised Commissioning to various professional bodies;
Chair of Pain of Urogenital Origin Taxonomy Group, SIG of International Association for the IASP; member of European Association of Urology, Chronic Pelvic Pain working group; executive
member (Honorary Treasurer Elect) of British Pain Society;
Chair of the BPS Pain Patient Pathway Maps Executive Committee and member of its implementation Committee; Chair of the
Scientific Committee, 1st World Congress on Abdominal and
Pelvic Pain; member of the medical charity SPIN; and Consultant on research for Mundipharma.
References
1 The Map of Medicine and the British Pain Society. Initial Assessment
and Early Management of Pain. London: Map of Medicine, 2012
2 The Map of Medicine and the British Pain Society. Chronic Widespread Pain, Including Fibromyalgia. England View. London: Map
of Medicine, 2013
3 The Map of Medicine and the British Pain Society. Low Back Pain and
Radicular Pain. England View. London: Map of Medicine, 2013
4 The Map of Medicine and the British Pain Society. Pelvic Pain.
England View. London: Map of Medicine, 2013
5 The Map of Medicine and the British Pain Society. Neuropathic Pain.
England View. London: Map of Medicine, 2013
Neuropathic pain
6 Elliott AM, Smith BH, Penny KI, Chambers WA, Smith WC. The epidemiology of chronic pain in the community. Lancet 1999; 354: 124852
7 Smith BH, Elliott AM, Chambers WA, Smith WC, Hannaford PC,
Penny K. The impact of chronic pain in the community. Fam Pract
2001; 18: 292 9
8 Bridges S. Chronic Pain. In: Craig R, Mindell J, eds. Health Survey for
England 2011. Leeds: Health and Social Care Information Centre,
2012. https://catalogue.ic.nhs.uk/publications/public-health/surveys/
heal-surv-eng-2011/HSE2011-Ch9-Chronic-Pain.pdf
9 Jensen TS, Baron R, Haanpaa M, et al. A new definition of neuropathic pain. Pain 2011; 152: 22045
10 Bowsher D. Neurogenic pain syndromes and their management.
Br Med Bull 1991; 47: 644 66
11 Torrance N, Smith BH, Bennett MI, Lee A. The epidemiology of
chronic pain of predominantly neuropathic origin: Results from a
general population survey. J Pain 2006; 7: 2819
12 Smith BH, Torrance N, Bennett MI, Lee AJ. Health and quality of life
associated with chronic pain of predominantly neuropathic origin
in the community. Clin J Pain 2007; 23: 1439
13 Doth AH, Hansson PT, Jensen MP, Taylor RS. The burden of neuropathic pain: a systematic review and meta-analysis of health utilities. Pain 2010; 149: 33844
14 Wild S, Roglic G, Green A, et al. Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030. Diab Care 2004;
27: 1047 53
15 Finnerup NB, Sindrup SH, Jensen TS. The evidence for pharmacological treatment of neuropathic pain. Pain 2010; 150: 57381
16 Attal N, Cruccu G, Baron R, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol
2010; 17: 1113 88
17 Haanpaa M, Backonja M-M, Bennett M, et al. Assessment of neuropathic pain in primary care. Am J Med 2009; 122: S1331
18 Haanpaa M, Attal N, Backonja M, et al. International Association for
the Study of Pain NeuPSIG guidelines on neuropathic pain assessment. Pain 2011; 152: 1427
19 Dworkin RH, Panarites CJ, Armstrong EP, et al. Is treatment of postherpetic neuralgia in the community consistent with evidencebased recommendations? Pain 2012; 153: 86975.
20 Torrance N, Ferguson J, Afolabi E, et al. Neuropathic pain in the community: more under-treated than refractory? Pain 2013 (Epub
ahead of print). http://dx.doi.org/10.1016/j.pain.2012.12.022
21 Hall GC, Carrol D, Parry D, McQuay HJ. Epidemiology and treatment
of neuropathic pain: the UK primary care perspective. Pain 2006;
122: 156 62
22 National Institute for Health and Clinical Excellence (NICE). Neuropathic PainPharmacological Management. Clinical Guideline 96.
London: NICE, 2010.
23 British Pain Society (BPS). Opioids for Persistent Pain: Good Practice.
London: BPS, 2010
BJA
24 British Pain Society (BPS). Neuropathic Pain. Working Group Consensus Opinion. London: BPS, 2012
25 National Institute for Health and Clinical Excellence (NICE). Spinal
Cord Stimulation for Chronic Pain of Neuropathic or Ischaemic
Origin. Technology appraisal 159. London: NICE, 2008
26 National Institute for Health and Clinical Excellence (NICE). Deep
Brain Stimulation for Refractory Chronic Pain Syndromes (excluding
headache). Interventional procedure guidance 382. London: NICE,
2011
27 Irving G, Backonja M, Rauck R, et al. NGX-4010, a capsaicin 8%
dermal patch, administered alone or in combination with systemic
neuropathic pain medications, reduces pain in patients with postherpetic neuralgia. Clin J Pain 2012; 28: 1017
28 BMA, Royal Pharmaceutical Society. British National Formulary. 64
(September 2012). London: BMJ Group and Pharmaceutical Press,
2012
29 Bennett MI, Attal N, Backonja MM, et al. Using screening tools to
identify neuropathic pain. Pain 2007; 127: 199 203
30 Goebel A, Barker C, Turner-Stokes L, Guideline Development Panel.
Complex Regional Pain Syndrome in Adults: UK Guidelines for Diagnosis, Referral and Management in Primary and Secondary care.
London: Royal College of Physicians, 2012. http://www.rcplondon
.ac.uk/resources/complex-regional-pain-syndrome-guidelines
31 Finnerup NB, Otto M, McQuay HJ, et al. Algorithm for neuropathic
pain treatment: an evidence based proposal. Pain 2005; 118:
289 305
32 Smith BH, Higgins C, Baldacchino A, et al. Gabapentin as a drug of
abuse. Br J Gen Pract 2012; 62: 4067
33 Cruccu G, Gronsethb G, Alksne J, et al. AAN-EFNS guidelines on
trigeminal neuralgia management. Eur J Neurol 2008; 15:
1013 28
34 Shaikh S, Yaacob HB, Rahman RBA. Lamotrigine for trigeminal neuralgia: efficacy and safety in comparison with carbamazepine. J Chin
Med Assoc 2011; 74: 243 9
35 Edlund MJ, Martin BC, Fan MY, et al. Risks for opioid abuse and dependence among recipients of chronic opioid therapy: results
from the TROUP study. Drug Alcohol Depend 2010; 112: 90 8
36 Stannard CF. Opioids for chronic pain: promise and pitfalls. Curr Opin
Support Palliat Care 2011; 5: 1507
37 Turner JA, Hollingworth W, Comstock B, Deyo RA. Comparative effectiveness research and policy: experiences conducting a coverage with evidence development study of a therapeutic device.
Med Care 2010; 48: S129 36
38 Chaparro LE, Wiffen PJ, Moore RA, Gilron I. Combination pharmacotherapy for the treatment of neuropathic pain in adults. Cochrane
Database Syst Rev 2012; 7: CD008943
39 Turk DC, Audette J, Levy RM, et al. Assessment and treatment of psychosocial comorbidities in patients with neuropathic pain. Mayo
Clin Proc 2010; 85(3 Suppl.): S42 50
79